Doctors, nurses, and medical professionals recognize their duty to care for their patients and to avoid making any decisions or taking any actions that could lead to further complications or additional injuries. Patients entrust their well-being (and their lives) into the hands of these medical professionals, hoping that these highly-trained doctors, surgeons, and nurses will uphold their professional obligation to care for them as much as possible. Unfortunately, there are times when a healthcare professional may act negligently or make a mistake that can trigger health complications in the patient or subject them to further harm or injury. Medical malpractice is generally defined as “negligence committed by a healthcare provider—a doctor, nurse, dentist, technician, hospital or hospital worker—whose performance of duties departs from the standard of practice of those with similar training and experience, resulting in harm to a patient or patients.” In other words, any medical professional who fails to uphold the standard of care owed to their patients and causes further harm or injury to the patient may be held liable for medical malpractice in Washington state. There are many types of medical malpractice claims, from surgical errors to delayed diagnosis to medication errors.
One issue that can lead to patient harm and may constitute medical negligence in Washington state concerns mistakes in a patient’s medical history. Maintaining accurate medical records is critical to ensure that patients receive timely and accurate diagnoses and appropriate treatment. Even a seemingly minor oversight or error in a patient’s medical chart can lead to serious complications and adverse outcomes. If you are interested in learning more about filing a medical documentation error claim in Washington state, the highly qualified and trusted team at Menzer Law Group is here to help. Our firm is deliberately selective in the cases we choose to represent so that we can devote our attention and leverage our expertise on those cases where we believe we can have the most meaningful and lasting impact. Today, we will explore some of the ways that doctor charting errors can affect patient outcomes, how to fix a medical record mistake, and your options for pursuing an inaccurate medical history malpractice claim in Washington state.
Recognizing Some Common Types of Charting Errors
There are many types of errors and mistakes that can appear on someone’s medical chart and become a part of their medical history. Even though medical professionals are required to keep detailed and accurate written records for each patient, oversights or incorrect information can trigger complications like delays in diagnosis and critical care. Here are just a few common charting errors that can affect patients in Washington state.
Missing or Incomplete Information
Details that are omitted or missing from a patient’s medical chart can lead to serious complications. For instance, if medical test results are not entered into the medical history, this can lead to a critical delay in care and treatment, potentially causing worsening patient outcomes. Or, missing information about a patient’s allergy to certain medication can lead to serious (and even life-threatening) scenarios if the medical professionals administer such medication. Gaps in the medical record can make it difficult for treating physicians to get the complete picture of the patient’s health, which can lead to delayed diagnosis or misdiagnosis.
Mislabeling Conditions or Behaviors
In some cases, a doctor or medical professional may incorrectly diagnose a patient’s condition or behaviors. For instance, a patient may be labeled as depressed or bipolar without undergoing a formal diagnostic process. This misclassification can create several complications for the patient, such as being prescribed medications that they do not need or that are not appropriate. In other cases, a healthcare professional may incorrectly document a patient as having a drug problem, when there is no evidence of this concern. Inaccurate and incorrect diagnoses or labels can create several barriers for patients, depriving them of the right treatment and care they need.
Copy-Paste or Documentation Mistakes
In an effort to save time, medical professionals or administrators may use copy-paste or template cloning to streamline the charting process. However, relying on these shortcuts can carry forward outdated, inaccurate, or irrelevant information, potentially overriding the most critical notes about the patient. In other cases, medical professionals may have too many windows open when completing patient charts, leading to mixed-up patient information or details entered into the wrong patient’s medical history.
How Medical Charting Errors Can Cause Patient Harm
Any error or oversight on a patient’s medical chart has the potential to affect their treatment and prognosis. Below are just a few of the ways that doctor charting errors can subject patients to further harm, injury, or adverse health outcomes.
Incorrect Treatment Decisions
Missing information, such as test results or properly documented symptoms, can lead to misdiagnosis, especially if the doctor does not have the right documentation to arrive at an accurate diagnosis. Or, mixed-up patient records can incorrectly identify serious health conditions in a patient who is actually in good health. Once the medical team has arrived at an incorrect diagnosis, they may recommend or subject the patient to unnecessary, ineffective, or (in some cases) harmful treatments. For example, incorrectly diagnosing the presence of cancer due to mixed-up patient records can lead a cancer-free patient to undergo radiation or chemotherapy—both of which carry intense side effects.
Delayed Care
Incorrect diagnoses or missing information in a patient’s medical record can prompt the attending physician to overlook serious health concerns, such as an impending stroke or the presence of cancer. Such oversights can then lead to a delay in treatment and care, which can cause a deterioration in the patient’s condition and overall health.
Misclassification and Stigma
If a medical professional incorrectly identifies a patient as depressive or bipolar, this can create several complications. For instance, the patient may experience the stigma of having one of these labels erroneously associated with them. Future providers may see this label and treat the patient through a different lens, potentially denying them the appropriate treatment or care they need.
Impact on Future Health Care Providers
When a medical charting error follows a patient to another clinic or provider, the patient can experience several difficulties. The erroneous or inaccurate chart details can prevent the new provider from accurately assessing the patient and recommending appropriate treatment, possibly denying them the care they need to support their health or even subjecting them to additional injury or harm because of these errors in their medical history.
How to Fix a Medical Record Mistake in Washington State
If you suspect that there is an error in your medical record, it’s important to recognize that you have the right to take action and ensure the accuracy of your medical history. Here are some of the steps you can take if you discover an error in your medical record.
Request and Review Records
Patients have the right to access their medical records at any time. Once you have these documents, you can review them carefully to identify any mistakes or missing information.
Submit a Correction Request
Under Washington law, patients have the right to provide a written request to their health care provider to “correct or amend its record of the patient’s health care information.” You will need to submit this written request along with an explanation of how and why the record is inaccurate or incomplete. If the healthcare provider agrees with your request, they will amend the record. However, if they deny your request, you are allowed to have your written request permanently included in your medical history.
Document All Communication
It’s important to keep a record of all correspondence with your healthcare provider. Should this matter develop into an incorrect medical records lawsuit, these communications will be useful to help you build your claim.
When Charting Errors Become Medical Malpractice in King County
Not every medical documentation error automatically constitutes medical malpractice. However, there are times when an error in a patient’s medical chart can trigger harm or injury, which may entitle the patient to recover compensation for the damages they suffered as a result of the error. In order to build a successful medical malpractice claim in Washington state, you will need to provide sufficient evidence that proves how the inaccurate records caused injury or harm. You will also need to establish that the medical professional who made the error failed to uphold the standard of care owed to you as their patient. If you are interested in learning more about your options for filing a medical malpractice claim in Washington, consider reaching out to a top Seattle medical malpractice law firm to get started.
FAQs About Incorrect Medical Chart Claims
Can I correct errors in my medical record?
Yes, you can send a written request, along with sufficient reasoning, to your healthcare provider to amend the error.
What if a doctor wrote something inaccurate about my condition?
You have the right to write to your healthcare provider, asking them to correct this inaccurate information. If the healthcare provider does not honor your request, you can file a formal complaint.
Can charting mistakes lead to a malpractice lawsuit?
In some cases, yes. As long as the patient can provide clear evidence that the charting error led to further harm or injury, and that the standard of care was breached, the plaintiff may be able to file a claim.
Learn More About Medical Malpractice Claims Today
If you or a loved one has suffered an injury or health complication at the hands of a negligent doctor, nurse, or health care professional in Washington state, you may be entitled to recover compensation from the at-fault party (or parties). As one of Seattle’s top medical malpractice law firms, Menzer Law Group is deeply committed to serving each client with the care, attention, and respect they deserve during this challenging time. We are intentionally selective in the cases our firm takes on so that we can focus our attention and expertise on those cases where we believe we can have the most significant and lasting impact. Please reach out to our Seattle office today by calling (206) 903-1818 to arrange a complimentary review of your claim.
